Evidence Based Shoulder Exercises For Muscle Imbalances (2024)

The shoulder is a very complex joint, one of the most complex in the human body. Moreover, it is the most mobile joint, which means that as a result, it must sacrifice some of its stability. It is imperative for the musculature and soft tissue structures surrounding the shoulder to be bulletproofed with strength in order to give that stability the shoulder needs to function at its optimal capacity. In this article, we will be demonstrating and explaining our favorite evidence-based shoulder exercises. Principles of biomechanics, kinesiology, and electromyography will be explained as well and you’ll learn how to increase targeted muscle activation, improve scapular muscle activation sequencing, and challenge shoulder stability!

Proximal Stability Promotes Distal Mobility

Shoulder and neck pain dysfunction are among some of the most common complaints of the overhead athlete and desk-bound workers alike. Recent research has shed light on the importance of the scapular muscles in shoulder and neck pain dysfunction. The scapula serves as our shoulder’s stable base. We need a strong and stabilized scapula in order for our shoulder joint to move properly. Proximal stability promotes distal mobility, folks! Based on research, overhead athletes are more likely to recruit the upper trapezius muscle prior to lower or middle trapezius muscles (1). This can lead to a timing issue in terms of muscle recruitment. Because of this, lower and middle trapezius and serratus anterior activity may decrease, while upper trapezius, pec minor, and levator scapula activity may increase. This group of dysfunctions can lead to a decrease in scapular upward rotation, external rotation, and posterior tilt – all specific scapular motions that are imperative to try and prevent things like subacromial pain syndrome and rotator cuff tendinopathy.

Posterior Cervical and Thoracic Musculature

The image above highlights some of the muscles situated on the posterior aspect (back) of our bodies. As you can see, the trapezius is a big muscle, that covers a large area of our back. As previously mentioned, there is anupper, middle, and lowertrapezius muscle. The upper trapezius helpselevate our scapula, whereas the middle trapezius performs scapularretraction, and the lower trapeziusdepressesour scapula. Understanding how to engage these muscles properly is an important aspect of rehabbing as well as preventing shoulder injury!

Understanding Force Coupling of The Shoulder Girdle

Because the shoulder is so complex, we want to break down the basics of a term known as force coupling, and which ones exist for this area of the body. Force coupling is whentwo or more muscles or groups of muscles, onopposite sides of a joint work together to provide proper stability and movement coordination to a particular joint segment (2). You can think of the shoulder as a golf ball on a tee. The humeral head (head of the shoulder) is much larger than the glenoid fossa (joint cavity) that it is situated within, hence its ability to be so mobile. This is why the margin of error in regards to movement coordination and sequencing is higher than other areas of the body, and force coupling plays a large role in minimizing that error! Below are the various force couples of the shoulder girdle.

Are You In Need Of Specific Shoulder Programming?

The Shoulder [P]Rehab Program is a physical therapist developed, step-by-step program that teaches you how to optimize your shoulder health. This 4-phase program will expose you to various scapula and shoulder strengthening and stabilization exercises supported by science. This program will bulletproof your shoulders for anything life throws at you! Learn moreHERE!

Force Couples of The Shoulder: Deltoid-Rotator Cuff

This particular force couple produces thelargest amount of force on the shoulder (2). As the arm begins to elevate, the larger, greater force producer deltoid muscle has a directional force on the humerus that is upward and outward. If this motion were to beunopposed, it would result insuperior migration of the humerus that can lead to impaction on a bony prominence called the acromion process,potentially leading to pain and injury!

This upward and outward motion iscounteracted by the rotator cuff muscles, which act iscompressors of the humeral head, keeping that portion of the bonecentered within the glenoid (socket of the shoulder) as the arm moves.

Deltoid-Rotator Cuff Force Coupling

Force Couples of The Shoulder: Rotator Cuff Anterior-Posterior

As previously discussed with the deltoid-rotator cuff force couple, the rotator cuff’s job is to keep the humeral head centered within the glenoid, creating a compression mechanism. There are 4 rotator cuff muscles, which are situated in both the front (anterior) and the back (posterior) of the shoulder. A good analogy when thinking of the rotator cuff is it is situated like a blanket that is covering the shoulder joint. If you want to learn more about the rotator cuff, read our blog post below!

Rotator Cuff Anatomy – Anterior & Posterior Views

In this blog article below, Craig breaks down how to assess for rotator cuff injury and excellent exercises that you can perform specifically for the rotator cuff!

READ: EXERCISES FOR ROTATOR CUFF INJURY

Force Couples of The Shoulder: Upper Trapezius And Serratus Anterior

These muscles work with one another to produce proper upward rotation of the shoulder. As stated previously in this article, literature has shown that oftentimes, the upper trapezius may become more hyperactive in individuals, whereas the lower trapezius is not as active, which can lead to abnormal scapular movement. This force couple of the trapezius and serratus anterior has 4 important actions (2,3):

• • Allows for rotation of the scapula, maintaining the glenoid in an optimal position

• • Maintains the effective length-tension relationship for the deltoid

• • Prevents impingement of the rotator cuff from the subacromial structures

• • Provides a stable scapular base enabling appropriate recruitment of the scapulohumeral muscles

Trapezius And Serratus Anterior Force Couple

The arrows above in this picture are exemplifying the direction in which muscle contractions will move the scapula. For instance, the red arrow pointing down towards the middle of the spine is highlighting the action of the lower trapezius, which is to depress the scapula, whereas the yellow arrow is demonstrating the upward rotation that occurs from the action of the serratus anterior.

Avoid These Common Mistakes With Shoulder Rehab!

Selective Muscle Activation

The glenohumeral joint, AKA the shoulder, is so fascinating to the anatomist because it demands chronologic, selective muscle recruitment. As a unit, the different trapezius muscle fibers should activate at specific times with balanced force couples to help move the arm in various directions. Work, hobbies, sports, and performing repeated movements will reinforce movement patterns in the brain, regardless of whether those movements are good or bad. Altered muscle activity and recruitment patterns may increase stress on structures, which may cause mechanical pain or injury (4).

How do we fix this? By training the brain to learn a new movement pattern. Learning and performing selective muscle activation sequences during specific movements is a way to tap into the nervous system. Here we show one way to train the brain via biofeedback. This is an electromyography device that uses surface electrodes placed on the upper trapezius. Listen to the different cues Mike provides Craig and listen to the change in muscle activity measured by the biofeedback device. We understand that not everyone has this machine at their disposal, however, visual and tactile cues can be used to accomplish the same goal. A legit evidence based shoulder exercise!

LISTEN: IMPROVING YOUR OVERHEAD SHOULDER STABILITY

Sharapovas

Maria Sharapova,the former world’s #1 women’s tennis player has had quite a remarkable career. But before she reached that #1 spot, she had to battle through a host of well-documented shoulder injuries that hampered her career early on. Rumor has it that this exercise, in particular, helped REHAB and [P]REHAB her shoulder back to health, hence the aptly named “Sharapova” exercise. It’s an absolute rotator cuff killer that hits the infraspinatus and teres minor isometrically, concentrically, and eccentrically.

Sample Shoulder [P]Rehab Program Exercise

• HOW: Start by looping a band around your wrist. Stand close to a wall with your elbows on the wall straight out from your shoulders making your palms face each other. Keep your elbows in as you create tension in the band with your shoulders. Keep one arm stable as you move the other arm slightly in, up, and then out holding that tension on the wall once you go out. Repeat on the other side going up and down.

• FEEL: You should feel your shoulder muscles working.

• COMPENSATION: Don’t create tension in the band with your wrist or hands, keep them relaxed and only use your shoulders. Keep a bend in your elbow, even when you move up and down on the wall. Keep your back up straight, don’t lean forward or backward.

The Prehab membership is the anti-barrier solution to keeping your body healthy. Access state-of-the-art physical therapy, fitness programs, and workouts online in the comforts of your own home or gym! Taking control of your health with exercise & education from the palm of your hand has never been easier. Get access to 50+ programs, 100+ unique workouts, and 3000+ exercises to build your own workout routines. Trial it for free, and learn how to get out of pain, avoid injury, and optimize your health with [P]rehab!

90/90 Scapular Stabilization

The upper trapezius becomes can overpower the middle and lower traps when it is too strong and hyperactive. The middle and lower trapezius are just as important during overhead exercises to promote optimal mechanics. More importantly, we have to learn how to activate the trapezius as a stabilizer, rather than a mobilizer, during certain glenohumeral joint motions.

Here is a great evidence-based shoulder exercise to increase mid and lower trap muscle activation. According to Maenhout et al 2016, the highest middle trapezius and lower trapezius muscle activation were found in prone exercises. Why is training the scapular stabilizers at a 90/90 degree shoulder abduction and external rotation so important? Well look how familiar this position is; think of a pitcher throwing or a CrossFit athlete performing an overhead movement. The shoulder is vulnerable in this position due to the risk of instability of the anterior/inferior glenohumeral joint capsule. Also, the labrum is speculated to be weak in this position. Therefore, we have to train our scapular stabilizers and rotator cuff to be strong in this position!

Be sure to avoid hiking your shoulders into your ears and keep your elbow relatively stable with as little movement as possible during this exercise. Note: I tried to exaggerate excessive upper trap use in the first rep!

Overhead Carries

Any form of a loaded carry is always a go-to exercise. This is especially true for overhead carries, which are a great way to train proper shoulder muscle recruitment under heavy load. You need good lower trapezius, serratus anterior, and upper trapezius muscle activation to maintain a stable, upwardly rotated scapula. Not only that, but the ability to maintain a stable humerus in the overhead position places a huge demand on the rotator cuff.

While standing, grab a kettlebell and hold it overhead with a slight bend in your elbow. Maintain this position as you walk forward for the prescribed amount of time or distance. The goal here is to maximally activate the scapular upward rotators to provide a stable base when under an overhead load. The cue I like to use with my patients is to “point the bottom of your scapula forward.” I find this helps promote scapular posterior tilt and external rotation (in addition to proper scapular upward rotation).Making sure to maintain a nice window of space between your neck and shoulder is a great way to ensure you’re not excessively using your upper traps.

Trapezius Targeted Interventions

The side lying shoulder external rotation exercise was 1 of 4 evidence-based shoulder exercises which were found to display the BEST muscle activation ratios in which upper trapezius activation is minimized and middle and lower trapezius activation is maximized by Cools et al 2007. The prone and sidelying positions decrease the upper trap’s activation as a postural muscle. When you stand, the upper trap is more active as its works against gravity. Laying on your stomach or side eliminates the effects of gravity and can decrease excessive activation!

Sample Shoulder [P]rehab Program Exercise

Start by lying on your side with your knees bent. Bend the top arm’s elbow to make a 90-degree bend or an “L’ shape. Support your head with your other arm or a pillow. Hold a dumbbell with your palm facing your stomach. Rotate the arm up and out while keeping that “L” shape in your elbow. Your thumb should be pointing up as the arm comes off of your stomach. Pretend there is a rod going from your shoulder through the bottom of your elbow and that rod has to stay still. Keep that elbow at your side as you rotate that arm up and back down to the starting position. An important aspect of this exercise is to not allow the elbow to come up or back as you rotate the dumbbell up. Also, don’t lean back with your body, stay on your side.

Plyometric Serratus Anterior Push-Ups

Scapular muscles play a huge role in controlling and stabilizing shoulder movement. One cannot address the shoulder without first addressing the scapula. The serratus anterior is among the important anterior scapular muscles. Scapular winging (i.e. SICK scapula) is a condition where the medial scapular border moves away from the rib cage. Think of the shoulder blades being close together in a resting position, similar to a bird with its wings closed. Now picture those wings ‘opening up’ when the bird goes flying. When humans move their arms overhead, the shoulder blades should only move away from one another, NOT the ribs. Scapular winging could be caused by an anterior scapular stabilization issue due to a motor control problem or muscular weakness.

Place a bosu on the ground with the blue side up. Place your hands on the ball about shoulder width apart with your elbows straight, feet straight out, and your toes pushing into the ground. Perform a normal push-up and at the bottom explode up by pushing off the ball as quickly as you can. Land in the push up position and repeat.

In order to improve this movement pattern, you have to perform exercises that INCREASE the recruitment of the anterior scapular stabilizing muscles, specifically the serratus anterior.

According to Maenhout et al. 2016, this evidence-based shoulder exercise increases serratus anterior activity in the backward push-off phase GREATER than in the landing phase (5). This is a great exercise for athletes who are returning to sports AND those who are currently playing.

Dynamic Scapular Stability Drill

Demonstrated here is a dynamic mobility and stability drill for anterior scapular muscles. The important thing to appreciate and recognize is that this movement is different than just moving your arm freely in all directions on the wall. As I do the exercise, I apply a constant isometric force by pressing my hand into the wall as I move the slider. This external cue of ‘push into the wall’ recruits the anterior scapular musculature (eg serratus anterior and pec minor muscles) to be active and provide scapular stability.

Demonstrated here is a dynamic mobility and stability drill for anterior scapular muscles. The important thing to appreciate and recognize is that this movement is different than just moving your arm freely in all directions on the wall. As I do the exercise, I apply a constant isometric force by pressing my hand into the wall as I move the slider. This external cue of ‘push into the wall’ recruits the anterior scapular musculature (eg serratus anterior and pec minor muscles) to be active and provide scapular stability. The particular sequence of scapular movements I demonstrate is as follows:

• Protraction and upward rotation

• Protraction

• Protraction and downward rotation+depression

• Protraction and upward rotation+elevation

• In summary, we are working on shoulder blade mobility and stability in all directions!
  

It is important to note that performing closed-chain exercises similar to this (hand on the wall) increases the activity of the rotator cuff muscles (6). Increased activity of these muscles increases the dynamic stability of the shoulder during movements. Remember, the rotator cuff muscles do not move the shoulder! They originate on the scapulae and insert on the humerus. This anatomical arrangement dictates that the rotator cuff’s specific job is to provide dynamic stability to the glenohumeral joint. It’s what helps to keep the humeral head within the glenoid fossa during any movement. Proximal stability at the shoulder will facilitate optimal distal mobility.

Bulletproof [P]Rehab Warm-up

Your warm-up should always incorporate priming your nervous system and target muscles for your specific lifts. This is one of my favorite shoulder warm-up movements!

1) Face-Pull: This exercise is a modified row movement. It targets the RHOMBOIDS and more importantly, the MIDDLE TRAPEZIUS to get good activation. Additionally, EMG studies have shown that the face-pull has one of the highest average and peak EMG activities for the posterior AND middle deltoids, too!

2) Shoulder external rotation in a 90/90 position: This exercise achieves concentric, eccentric, and isometric activation throughout. It also induces the exact same shoulder position of any overhead movement like the press or snatch. Strengthening in this position is key for functional carry-over into CrossFit.

3) Resisted Y-Upward Rotation: This exercise primes your serratus anterior, upper traps, AND lower traps due to the particular angle of the arm in the scapular plane.

Closing Thoughts

After reading this article, you now have gained an understanding of how the shoulder girdle functions, and excellent evidence based shoulder exercises you can implement into your routine to bulletproof your shoulder! Always remember to focus on your form with exercise. The key with many of these exercises is intentional movement, meaning focusing your mind on what muscles you are trying to activate and staying focused on that goal throughout the entirety of the movement! At first, it may be difficult to get a feel or ensure you are having the right activation of particular muscles, but this is normal! It is all part of the motor learning process. Ultimately, the more you practice these types of exercises, the more natural they will become.

The Ultimate Shoulder Programming At Your Fingertips!

To win an NBA championship in this current era it seems at least 3 superstars are needed on the team. Behind these 3 superstars includes the entire support staff that takes care of the day-to-day operations allowing the stars to perform. Sounds like they are using the model of the shoulder! You will learn how to create balance among the support staff which will allow the 3 joints of the shoulder to perform to their superstar abilities!

References

1. Cools AMJ, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med. 2014;48(8):692–697.
2. Page, P. (2011). Shoulder Muscle Imbalance and Subacromial Impingement Syndrome in Overhead Athletes. International Journal of Sports Physical Therapy, 6(1), 51-58.
3. Fongemie, A., Buss, D., & Rolnick, S. (1998). Management of Shoulder Impingement Syndrome and Rotator Cuff Tears. Journal of American Family Physician, 15(57), 4th ser., 667-674.
4. Castelein B, Cools A, Bostyn E, Delemarre J, Lemahieu T, Cagnie B. Analysis of scapular muscle EMG activity in patients with idiopathic neck pain: A systematic review. J Electromyogr Kinesiol. 2015;25(2):371–386.
5. Maenhout A, Benzoor M, Werin M, Cools A. Scapular muscle activity in a variety of plyometric exercises. J Electromyogr Kinesiol. 2016;27:39–45.
6. Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of Scapular Muscle Balance: Which Exercises to Prescribe? Am J Sports Med. 2007;35(10):1744–1751.

About The Author

Craig Lindell, PT, DPT, CSCS

[P]Rehab Co-Founder & Chief Content Officer

Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.